Remote AIM Transitions RN Care Coordinator II, CA

Sutter Health

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Job ID R-43775
Date Posted 07/10/2023
Location San Mateo, California
Schedule/Shift/Weekly Hours Regular/Days/40


SCAH-Sutter Care at Home – Bay


Position Overview:

Advanced Illness Management (AIM) Transitions/Telesupport RN Care Coordinator – Hybrid position Requiring Home based care delivery and virtual care delivery.

The AIM Transitions RN Care Coordinator (RNCC) provides specialized nursing services to patients nearing the end of life. The Transitions/Telesupport Nurse manages a caseload of patients with advanced illness who are participating in the AIM Program. The Transitions/Telesupport Nurse provides care both in the home and through telephone support. He or She works within the 6 pillars of the AIM Program. The care provided focuses on care coordination, patient-coaching and decision-support, symptom management, advanced care planning, education relating to disease process and treatment options, psycho-social and spiritual care, and reduction of Emergency Room (ER) visits, inpatient hospitalizations, and timely transition to hospice. Other duties associated with the AIM program will be assigned as needed.


Job Description:


Graduate of an accredited school of nursing. Bachelor’s degree in nursing preferred.


  • RN-Registered Nurse of California
  • BLS-Basic Life Support Healthcare Provider
  • California Driver’s License
  • Valid Auto Insurance


  • 5 years’ experience in a home health and/or hospice position preferred.
  • One year of acute medical experience required.
  • Oncology or palliative care experience desirable.
  • Direct patient care experience within the past five years required.
  • Excellent clinical, critical thinking and assessment skills
  • Good interpersonal skills



  • Demonstrated proficient knowledge and competence regarding nursing theories, concepts, and practices; medical terminology; anatomy; and physiology.
  • Understanding of home care and hospice services and regulations, Title XXII, Medicare Conditions of Participation; infection control principles; excellent working knowledge of the principles of palliative care and demonstrated ability to work with patients with advanced illness.
  • Working knowledge of the healthcare industry, safety precaution policies, best practices regarding patient care and privacy, and changes in local/state/federal regulations.



Complete AIM program training.  Successfully pass AIM Program competency exam on annual basis with demonstration of knowledge in symptom management, understanding end of life issues with appropriate interventions and understanding of the impact of cultural background on illness management.

Possess excellent interpersonal skills enabling the AIM Program RN to discuss difficult issues

concerning clinical goal setting and transition toward end-of-life care with patients, families and


  • Be a self-starter with a high degree of initiative, motivation, flexibility, energy, and creativity.
  • Ability to work as part of an interdisciplinary team as well as form harmonious working relationships with internal and external customers.
  • Excellent collaborative and problem-solving skills with customers and management.
  • Ability to exercise independent sound judgment in planning and providing patient care. Demonstrated ability in physical, psychosocial, and environmental assessment skills and in implementing plan of treatment.
  • Possess written and verbal communications skills to explain sensitive information clearly and professionally to diverse audiences, including non-medical people.
  • Proficient knowledge of computer applications, such as Microsoft Office Suite (Word and Outlook, Excel, Teams), Electronic Health Record.
  • Time management and organizational skills, including the ability to prioritize patient care, assignments and work within standardized policies, procedures, and practices to achieve objectives and meet time sensitive activities.
  • Prioritize assignments and work within standardized policies, procedures, and scientific methods to achieve objectives and meet
  • Prioritize assignments and work within standardized policies, procedures, and scientific methods to achieve objectives and meet deadlines.
  • Work independently, as well as be part of the team, including accomplishing multiple tasks in an environment with interruptions.
  • Identify, evaluate, and resolve standard problems by selecting appropriate solutions from established options.
  • Ensure the privacy of each patient’s protected health information (PHI).
  • Build collaborative relationships with peers and other healthcare providers to achieve departmental and corporate objectives.


Essential job duties and physical demands include and are not limited to:

  • Administers nursing patient care in a home; be able to remain sedentary for approximately 50% of the day, maneuver around objects, climb stairs and/or work in relatively small spaces, bend over or stretch as necessary in care provision, operate telephone and manipulate small clerical items (e.g. paperclips, staples, etc.); ability to raise, lower, or transfer objects and supplies from one level to another; transport an object usually by hands, arms or shoulders; ability to bend, stoop, twist and lift and transfer up to 50 pounds in patient care.
  • Must be able to meet company productivity standards as indicated by organization. Must be able to hear, read, write, and speak clearly to effectively communicate with department staff, other Sutter Care at Home employees, community, and patients to carryout essential functions.
  • Must be able to deal with challenging work environment with time demands and occasional conflicting priorities. Maintain a positive and professional image and demonstrate self-directed learning to meet professional development and/or license requirements. Is responsible for maintaining all required licensure and certifications. At orientation and annually thereafter, must be able to meet AIM core competencies for position and area of specialty, as appropriate.



The Transitions Nurse -AIM Program performs general nursing clinical procedures which may include care coordination, patient coaching and decision-support, symptom management, psycho-social and spiritual care, advanced care planning, education of disease process and treatment options, resulting in reduction of ER visits and timely transition to hospice


Primary Job Responsibilities:

  • utilizes effective physical and psychosocial assessment skills, performs and documents multi-system assessments
  • determine red flags for individual patients with appropriate crisis plans to ensure patient and family are prepared to manage at home potential symptoms.
  • seeks appropriate and timely consultation for patients who have made insufficient progress towards identified goals
  • works collaboratively with other clinical and clerical team members and Home Health/ Hospice to meet patient plan of care and/or agency mission and objectives
  • timely notification to the primary physician and or AIM Administrator of emergencies and/or unexpected or significant changes in the patient medical condition
  • maintenance of positive working relationship with physicians by communicating clinically relevant information and progress on a frequent basis
  • consistent practice and teaching patient/caregiver infection control techniques in accordance with agency guidelines and regulations
  • demonstrates knowledge and appropriate utilization of internal and community resources to adequately meet patient needs


Quality Management (includes documentation and regulatory standards)

  • completes all clinical documentation in appropriate EMR in a timely manner including consents, clinical forms, physician and team communications and provision of clinical care.
  • Implement care according to protocols, policies and procedures and participate actively in continuous quality improvement activities to ensure program outcomes
  • implements and updates the plan of care in a timely manner in accordance with accepted professional standards of practice
  • demonstrates knowledge of and actively participates in the Quality Management/Quality Improvement Program
  • completes handoff work to other program and services
  • demonstrates improvement in patients’ pain and other targeted symptoms or takes appropriate clinical actions when symptoms are not resolved.
  • reduces emergency room visits and hospitalizations in AIM patients
  • consistently maintains and ensures maintenance and implementation of revised or new practices/procedures resulting from successful QI initiatives
  • demonstrates commitment to quality improvement by attending offered and/or mandatory staff in-services
  • reports potential customer service problems to Administrator in a timely manner and ensures prompt resolution of identified problems whenever feasible
  • ensures that patient complaints, incidents and unusual occurrences are handled diplomatically, promptly, and according to agency policy and procedure
  • participates in orientation of new staff and ongoing staff development and training



Care Management

  • Maintain a patient visit schedule for each case with awareness of other planned visits. (MSW, MD, etc.)
  • Prioritize visits based on patient needs and current information.
    • Refer to MSW and Chaplain as needed
    • Ensure visit type and frequency according to AIM acuity assessment tool.
    • Implement and maintain epic schedule per patient needs.
    • Establish tele-support schedule for patients not receiving home visits.
  • Complete all documentation in EHR within 24 hours
  • Attend all AIM Team Conferences
  • Prepare for AIM Team Conferences:
    • Identify cases to present: new patients, problem cases and handoffs
    • Prepare to present case and questions to team in proper format
    • Prepare to discuss reasons for hospitalizations and ways to avoid, if possible




  • Visit frequency to align with Acuity assigned to patient.
  • Oversees provision of patient care services for approximately 60-70 patients


  • Makes decisions subject to approval by Administrator or patients’ physician, patient and/or family for: referrals to home health services, referrals to community agencies, frequency of visits, intensity of care, pacing of patient instructions, referrals to Hospice/Home Health and discharge from service.
  • Meets visit productivity standards per agency policy
  • Not authorized to sign contracts or legal instruments that bind the agency to any agreement for goods and services.
  • May assist in the formulation of clinical policy.


The following job description permits this individual to access clinical, billing, and demographic Protected Health Information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA).


Pay Range -66.61 – 88.58 per hour


 Job Shift:




Full Time


Shift Hours:



Days of the Week:

Monday – Friday


Weekend Requirements:









This position is work from home eligible.


Position Status:



Weekly Hours:



Employee Status:



Number of Openings:



This position may regularly work, store, prepare, receive, unpack, transport, dispose of, or administer drug(s) identified as hazardous, or potentially hazardous, by the National Institute for Occupational Safety and Health (NIOSH) for purposes of USP 800.


Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.


Pay Range is $66.61 to $88.58 / hour


The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.